Provider Demographics
NPI:1124073929
Name:FISHER, KEITH C (PT, OCS, MTC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:C
Last Name:FISHER
Suffix:
Gender:M
Credentials:PT, OCS, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1212 MEMORIAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2247
Practice Address - Country:US
Practice Address - Phone:920-652-9554
Practice Address - Fax:920-652-9556
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2759-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391-99-7089OtherTRICARE
WI40144000Medicaid
WIK400172053Medicare PIN